I’m moving a couple states away to return to school, a Physician Assistant program that begins in June. And while I hope to try and work an occasional shift with a more local service, it remains to be seen whether that will be possible. So I’m now approaching a crossroads where, after approximately four years of wearing a patch on my shoulder (many different patches, to be sure), I might soon be giving it up forever.

It’s a strange sensation. It’s been pointed out that, unlike other professions — butcher and baker and candle-stick maker — EMS has a unique ability to dominate the lives of its men and women. How many doctors and nurses do you see with bumper stickers, tattoos, and T-shirts proudly advertising their trade? For many of us, you don’t work as an EMT or a paramedic, you are one; it’s part of our identity. (That’s why it can be so devastating when, through life or injury or the whimsy of employment, we suddenly find ourselves without a uniform to wear — many of us don’t know what to replace it with.) There are prominent physicians of many years who still include “NREMT-P” among their credentials. That’s like an attorney listing his high school oyster-shucking job on his CV.

There are probably many reasons for this. Buckman has observed that becoming an EMT is one of the fastest and easiest routes to “feeling important” — one quick class, and you can break traffic laws and tell everyone you’re a lifesaver. We like that, I’m sure. There’s a lot of ego in this business.

But I suspect that it also attracts people who embrace its fundamental nature. At the bottom, this job is about going to people in distress and helping them. And there is something in us — I think in everyone, although stronger in some — that wants to do that. It resonates with us as humans. (Of course, many other things resonate with humans, including sex and bacon and a great parking spot. But that’s all right. We’re complex creatures.)

The point is, this business allows us to play that role in a unique way. I believe that someday I may enjoy sitting in an office and treating patients who walk in the door, or waiting in an emergency department, or roaming a hospital floor. But that’s different; you are the all-knowing Man on the Mountain, and your patients come and form a line to beg for your wisdom. On the ambulance, people call for help, and we go to them. We take the trouble; we’re the humble servant. Yes, they have to ask, but once they do, we bring the noise, we say: “There, there. We’re here now. Everything’s going to be all right.” In the simplest, most fundamental template of this job, people have problems and they call us; we hear the call and we drive toward them; we walk into their home or business or any of the places that people go; we see a human being in distress; and we kneel beside them and ask, “How can I help?”

By coming to people in their time of need, we get closer to the heart of it all. By our willingness to kneel, we open ourselves for the dying eight-year-old to ask: “Mrs. Nurse, will you hold my hand? I’ve never died before and I’m scared.” And that’s special, and it’s not such a bad thing to elevate it, even though — as Thom Dick reminds us — no matter how much we love it, it won’t love us back.

No matter where I go from here, for me, EMS will always be about that feeling of kneeling beside someone. Or the experience of sitting on the ambulance bench, alone, just my own thoughts and a trusting and vulnerable patient.

That moment when I walk into the room, and all eyes turn to me.

The mental perk-up as the radio crackles, and the extra acuity that dials in as I recognize my call sign and my gears start turning.

Opening my mouth to give a report to a trauma bay filled with nameless people wearing scrubs.

Holding an old lady’s hand as we bounce down the road.

Touching a shoulder as I say good-bye.

Iced coffee from Dunkin’ Donuts, titrated to my tiredness.

The smell, sound, and non-stop rumbling of a diesel engine.

Black shoe polish.

Sitting beside a partner and feeling like it’s the two of us against the world.

There’s a lot that’s wrong with this job. But there’s something that’s right about it, too, and it’s something important. And that’s why we keep coming back.

I’ll be busy soon, and this site will have to take a back burner. Updates will come less frequently, and I can’t guarantee new scenarios or new posts or new Library material on any reliable schedule. But wherever I end up, I don’t plan to turn my back on it. Because even if you leave the ambulance, I’m not sure if you ever stop being an EMT.

“Hi, my name is Brandon. I’m an EMT with Save-a-life Ambulance. Can I help you?”

Anybody remember that? I think it was on page 6 of the EMT textbook.

I suppose it’s about communicating your name, which is nice. And it’s about obtaining consent, which is important, although in reality, consent in EMS is usually handled the same way as consent in sexual activity — you just go until someone says stop.

But mainly it’s about courtesy and professionalism. It’s gauche to swoop into a room and just start playing with somebody’s lesions without so much as a how-do-you-do.

The trouble is that the formal intro is so hokey nobody actually uses it. Or uses anything remotely similar. And I think that’s a shame, because although it’s silly, it’s getting at something important.

We understand that people call us mainly to bring some order to their crisis. Obviously, that involves Doing Medicine. But the medicine is just a means to an end.

Why do we call plumbers? When your sink starts flooding water into the kitchen, you don’t know what to do. This situation is alien; it’s outside of your expertise. You may be very good at many things in life, such as fueling your car, tying your shoes, and making cherries jubilee, but you don’t know what to do about this.

You know that there are people who have the answers, though; they’re called plumbers. So you call a plumber, and say, make it right.

We’re the same way. People don’t know what to do when they get chest pain or crash their car. But they know that if they call 911, professionals will come who know what to do. So they call us. That’s why people sometimes ask 911 to fetch cats out of trees or ask when the circus is coming to town. It’s why the first reaction of so many motorists after a crash is to call their spouse or their dad.

The thing is, when we walk in and our first reaction is to Do Medicine, it’s not helping the problem. All that medicine is just more strangeness, unless your patient is a fellow clinician. So now their distress is going to continue until you can finally tell them what’s wrong. Except you won’t, because you don’t think you’re qualified for that. So now they’ll stay confused and scared until they get to the hospital. And on and on.

Throw them a rope!

The fastest way to restore normality to a situation is to reintroduce a familiar activity. And social courtesies are very familiar to everyone.

When you introduce yourself and shake someone’s hand, they’re transported from the confusing world of a medical crisis to something much more comfortable. They know how to do this. Smile, shake, say your name. It’s easy. They’re good at it.

Sometimes patients are visibly shocked when you do this, and seem to reset; you can literally watch them change channels. Now they’re a little calmer, a little happier, and you can work with that. With enough balls, you can pull this off in the most outrageous circumstances. Sing praise for the EMT who can walk in on the triple traumatic amputation and say “Hi! I’m Jim. What’s going on?”

Now, of course, you don’t want to minimize the patient’s distress. In an emergent situation, it can be galling and obnoxious for their freak-out to be met by your apparent apathy or boredom. That’s why you have to find a middle ground between projecting calm confidence and acknowledging the seriousness (perceived or real) of the patient’s situation. Don’t let them drag you along into panic, but don’t try to abruptly pull them to a halt either; strike a balance, pace them, and then gradually slow them back down. The point is that introducing yourself like a regular person is a powerful tool for restoring normality to a crazy situation: use that tool liberally, but intelligently.

I’ve had patients tell me I was the only Medical Person they could remember introducing themselves. That’s a damned shame. People greet each other and make a introduction when they meet. And aren’t patients people?

Streamlining a patient’s entry to the healthcare continuum is one of our main roles in EMS, and the key step in most cases is when we transfer care at the emergency department. This isn’t rocket science, but you can do it well or less well, and frankly I think it’s tough to do right unless you can see the whole picture. We never really know in what ways we’re setting up people effectively for their ED care and in what ways we’re part of the problem, unless perhaps we work on both sides.

So I asked for a little help here. I sat down virtually with Dr. Brooks Walsh, ED attending extraordinaire — author of Mill Hill Ave Command and Doc Cottle’s Desk — and with Jeff, an ED nurse from my area. We discussed how to work and play together better, including topics like handoff reports, useful histories, and typical ED courses of care.

Jeff’s hospital saves time in all trauma, stroke, and STEMI activations by assigning patients an alias immediately upon notification by EMS. That way registration isn’t lurking around while the team is trying to treat the patient.

Cath lab activations from the field are still often about trust — whether staff knows the individual provider or the particular service calling. Rightly or wrongly, there’s also a stricter de facto standard for activation during off hours when nobody wants to get out of bed.

For stroke, neurology may be in the room when you arrive, but more often, especially in smaller hospitals, they’re available by page or teleconference.

When bringing in the stroke, try and ensure that family who can testify to time-of-onset/time-last-seen-normal, as well as consent to treatment on the patient’s behalf, are present — ideally transported with you — not unavailable in a taxi somewhere.

When you walk in the room, the typical team is a doctor, a nurse, a tech, then any extras — residents or other students, surgery, pediatrics, whomever. And registration is the dude with the clipboard or computer, of course.

When reporting to the doc, focus on: first, anything that needs to happen immediately; second, information he can’t get elsewhere (i.e. not patient medical history unless it’s not available in the records, laundry list of negatives, etc.), such as how you found the patient, general context, changes en route, etc.

Written PCRs are usually not read due to difficulty obtaining them and general unfriendliness (hard to find info, obscure writing), but sometimes there’s useful stuff in there, particularly in the narrative itself.

Baseline patient info from EMS is great if we know the patient well (frequent fliers); baseline info from bystanders, staff, family etc. is okay but less reliable.

Get patients to their usual facility if at all possible, especially those with complex histories, and especially anyone with recent surgical history — otherwise they’ll just get transferred later.

“Take me to x, my doctor is there” (meaning PCP or specialist) — less important, but can be nice if there are chronic issues and they’d like to maintain the existing treatment plan.

Disagreements over patient triage or treatment: find the attending or perhaps resource nurse and voice your concern. In the long-term: raise issues with the hospital’s EMS liaison (either directly or through your internal chain of command).

People have problems, so they call the ambulance. We arrive and find them — mostly — seated in a chair, or lying in a bed, or perhaps down on the ground. Then we kneel beside them and introduce ourselves. We ask questions, put our hands on them, give medicines, and so on down that clinical flow you learned in school.

Here is what we don’t do: stand six feet away, look down at the patient (and maybe, maybe deign to bend over a little, with our hands on our thighs like we’re admiring a gregarious puppy), and shout in their direction. “Do you want to go to the hospital?” This is not yodeling practice. This is caregiving.

When did we stop kneeling? More and more, this practice seems to be spreading, and it’s reached the point where I can hardly remember the last time I saw one of us kneel beside a patient. Occasionally somebody will kneel to take vitals, but the provider actually speaking and interacting with the sick person still towers over them like a cop chalking off a body.

But we’re not talking about an Olympic sport here, okay? We’re talking about kneeling, at least for a moment, in whatever manner you can successfully perform. At the very, very least, sit down on something so you’re level with the patient. Park your butt beside them on the sofa or pull up a chair.

It’s about patient comfort, because they want to feel like they’re engaging with a fellow human, not yelling up at Rapunzel’s tower. But it’s also about the dynamic it creates between you. As a novice provider, when I first read Thom Dick write about humility, I didn’t understand. But as time passed, it made more and more sense to me (something that happens suspiciously often with Thom’s stuff). Body language says something, not just to others, but to yourself.

When you kneel, you’re saying: I’m here to help. I’m here to serve you. We don’t kneel very much anymore, not in the modern Western world, but we understand instinctively why one would kneel before a king. It’s not in spite of the effort it takes you to get down there, it’s because of it: by making yourself uncomfortable, you’re demonstrating a willingness to put someone else’s needs before your own.

It’s not saying that they’re your master, and you’re not making them the boss of anything. They’re not making you kneel, which is all the difference: it’s a gift, freely given. You’re acknowledging that the patient is important. More prosaically, it’s very much like the relationship that the cashier at Wal-Mart is supposed to have with you (at least in theory). If you met him on his day off, he might cut you off in traffic, flip you the finger, and drive away cackling. But while you buy batteries, at least, it’s his job to help you out. If he’s lucky, he enjoys doing that; if he’s not, he feels forced into it because he wants to keep his paycheck. We’re in a different boat, though, because our obligation doesn’t come from a boss looking over our shoulder. It comes from the fact that we accepted a duty (perhaps sacred, perhaps mundane, but a duty either way) — that when someone calls 911 and asks for our help, we’ll come and serve them. That makes us servants, and not in a bad way.

Something different happens when you refuse to lower yourself before a patient. It tells everyone in the room, including the patient and especially including yourself, that although you’re here, and although you might perform the clinically-indicated medical treatment, you’re not putting yourself out at all. Drive-by care is all you’re willing to offer. It’s like telling the patient: “Just to be clear, we were in the area anyway, and I thought you might have some snacks.”

I have great respect for police, and we work alongside them often. But their business is very different from ours, and it highlights the dangers in conflating the role of EMS with that of public safety. The job of a caregiver is to serve. The job of a cop is to enforce. It means they have to elevate themselves — you can’t exert authority unless you’re coming from a place of some kind of superiority (legal, moral, even physical). It means they have to judge. I don’t know if they enjoy it, and I do know that it’s highly necessary. But it takes a different kind of person, or at least a different kind of thinking, to judge people than it takes to serve them. Try to imagine a cop kneeling, or helping to wipe Mrs. Smith’s bottom. Now imagine yourself wearing aviators, crossing your arms and leaning against the wall while you bark at her, and understand that it’s just as misplaced.

What’s funny is that when you accept this “lesser” role, you can find an awful lot of meaning in it, because it’s a privileged place too. The privilege isn’t something you exert over others: rather, it’s freely granted to you by the patient. When they see that you’re here to help them, they give you permission to enter their home, to touch their body, to ask them the most intimate questions. This is essential, because you need that access to do your job (and it’s why I believe that mixing EMS and law enforcement would mean a major blow to our ability to treat people). But it’s still a gift. And I think that’s worth something. Even sore knees.

One more post about glucometry is pending, but for now, something lighter.

Decades of medical interns have been raised on the Laws of the House of God. The House of God was a cynical and dark look into the world of modern medicine, and its “Laws” were about as uplifting as condensed soup, but they rang true enough that you’ll still hear them quoted in the halls of medicine today (including those of the real-life “House of God,” where I find myself more shifts than not).

In any case, laws come in handy. Although I’m a believer in the nuanced and detailed analysis, as I age and my neurons gradually turn to cotton candy, I increasingly see the value in basic rules of thumb to guide us through the tangled web of life, and especially of this job.

A good law is simple. It’s always true, or almost always, and the exceptions prove the rule. It’s not specific to a certain region or company, but is something you can keep under your hat and carry with you throughout your career. It’s clear and it say something fundamental about the kind of provider you want to be. But most of all, a good law is not just an empty platitude, but rather an actionable guide-post that can answer real questions in real situations. When times are hard or temptations loom, it’ll tell you what to do.

With no further ado, then, here are mine. I believe in them, I follow them, and like good unguent, I wholeheartedly prescribe them for universal application. I am not wise, but whenever I do a good job of faking it, it’s by following these principles.

THE LAWS OF EMS

Help your patient in any way you can.

Be nice to everybody. It’s your job.

If you can’t save their life, make their day a little better.

Protect your partner.

Have a reason for everything you do.

Leave the patient better off than when they met you.

It should get calmer when you show up.

Good habits make doing the right thing easy.

Tomorrow, nothing will remain but your documentation.

Everything’s a bigger deal to the person on the stretcher.

But that’s just me. What laws do you believe in?

Editor’s note: this post was expanded into a feature piece for EMS World Magazine in the March 2014 issue.